New Hire Submission and Return Receipt PLEASE SUBMIT FORMS TO: OR FAX

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1 1933 E EDGEWOOD DR SUITE 102 LAKELAND, FL New Hire Submission and Return Receipt PLEASE SUBMIT FORMS TO: SERVICE@ADVANCEDPEO.COM OR FAX Notice to Client Company: NO Person shall be considered an employee of Advanced PEO Solutions, LLC until the NEW HIRE forms have been completed in full, signed, and submitted to Advanced PEO Solutions and Advanced PEO Solutions has notified your company by phone, fax, letter or that the new hire has been verified and accepted as an employee. (Refer to Client Service Agreement for details). CLIENT COMPANY MANE: It is clearly understood that no new hire will be placed in service by CLIENT COMPANY until the NEW HIRE applications have been received and approved by Advanced PEO Solutions. The CLIENT COMPANY also acknowledges that if CLIENT COMPANY does place such person into service for CLIENT COMPANY before receiving the required approval AND receipt from Advanced PEO Solutions, the person is NOT working under Advanced PEO Solutions workers compensation policy and the CLIENT COMPANY is totally and completely responsible for all liabilities and or penalties should any occur. Co- Employers Signature of Acknowledgement: (President/Owner) *MUST Be signed before turning in payroll to Advanced PEO Solutions. NEW HIRE NAME: (please print) Representative of Advanced PEO Solutions LLC will sign and return INTERNAL OFFICE USE: Date application received: Employee: Accepted Denied Reason: Date Client Notified: Contact Person: How Notified: Contact Info: Authorized by Advanced PEO Solutions Rep:

2 EMPLOYEE INFORMATION Advanced PEO Solutions, LLC (APS) is a professional employer organization, which means that APS is a co-employer of the employees working for its worksite employers/client companies. As a co-employer, APS is the employer of record for payroll, tax reporting, workers compensation insurance, claims management, and other possible administrative functions. The client company or worksite employer is responsible for the day to day work of the employees and otherwise running the client company. EQUAL OPPORTUNITY EMPLOYER We adhere to a policy of making employment decisions without regard to race, color, age, sex, religion, nationality, disability, handicap or marital status. If you require reasonable accommodation in completing the form, please inform us. PERSONAL DATA Full Name: SSN# Present Mailing Address: City ST Zip Former Address: City ST Zip Phone: Cell Phone: Type of work Desired: Part Time Full Time Are you 18 years of age or older? (if under 18, please state your age ) Date of Birth: (If you are under 18 years of age, employment is subject to verification that you are of legal minimum age and can furnish any required work permit) Are you on layoff subject to recall elsewhere? Explain: Are you prevented from lawfully becoming employed in this country because of VISA or Immigration Status? Date Available for Employment: Minimum Salary Requirement:$ Have you been employed here previously? If yes, when? Last Position Held: Have you ever been convicted of a crime, entered into a plea of nolo contendre (no contest) to a crime, pled guilty to a crime, had adjudication withheld or received a suspended sentence (regardless of the ultimate adjudication) for a crime? YES NO. IF YES, give details concerning the type of crime, the date of the conviction or plea, the penalty imposed, and any other circumstances you deem relevant to a full understanding of what occurred. Have you been arrested and charged with any misdemeanor or felony not disclosed above for which you are out on bail or free on own recognizance pending disposition or trial (do not include minor traffic violations/infractions for which no court appearance is necessary)? YES NO. IF YES, give the date and details of the arrest or charge and any other circumstances you deem relevant to a full understanding of what occurred. Have you ever been sued for causing death of, or injury to any person, or damage to any property (e.g., for assault, battery, defamation, etc.)? YES NO. IF YES, give details concerning the nature of the claims and defenses raised by the parties, the outcome of the action (e.g., settlement, jury verdict, or other disposition), and any other circumstances you deem relevant to a full understanding of what occurred. NOTE: Answering yes to the three previous questions is not an automatic bar to employment. Factors such as age at the time of the offense, seriousness and nature of the violation, relatedness to the job sought, and evidence of rehabilitation will be taken into account. However, please be advised that a misstatement or omission in answering these questions may be grounds for disciplinary action, including discharge. Number of Days Absent from Work Last Year: Do you have Transportation TO and FROM Work? Can you work overtime if asked? PLEASE READ THE FOLLOWING STATEMENTS BEFORE SIGNING BELOW The facts set forth in my application are true and complete. I authorize the investigation of all statements contained in this application and hereby authorize my former employers to furnish all information pertaining to my work record. I hereby release my former employers from all liability on account of furnishing such information. I understand that false statements, omissions, or misleading statements on this application shall be considered sufficient cause for refusal to hire or dismissal and I agree that my employer shall not be held liable in any respect if my employment is terminated because of such omission, or false or misleading statements. Advanced PEO Solutions, LLC is hereby authorized to investigate my employment history, including the contacting of the employers listed previously. SIGNATURE: Date:

3 PLEASE PRINT NAME AS IT APPEARS ON YOUR SOCIAL SECURITY CARD Employee s Withholding Allowance Certificate OMB No Form W-4 Whether you are entitled to claim a certain number of allowances or exemption from withholding is Department of the Treasury 2015 Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 1 Type or print your first name and middle initial. Last name 2 Your social security number Home address (number and street or rural route) City or town, state, and ZIP code 3 Single Married Married, but withhold at higher Single rate. Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box. 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 6 Additional amount, if any, you want withheld from each paycheck I claim exemption from withholding for 2011, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.) Date 8 Employer s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) 5 6 $ For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 Instructions and worksheets for completing the W-4 furnished upon request. Emergency Contact Name Relationship Phone Numbers SECTION 2 TO BE COMPLETED BY EMPLOYEE S SUPERVISOR OR MANAGER Client Company: Client Location: Dept. Name or Number: Date of Hire: Pay Cycle: Weekly Pay Type: Full Time Bi-Weekly Semi-Monthly Monthly Part Time Job Title: Workers Comp Class Code: ( If unsure of class code, contact Advance PEO Solutions) Supervisor, Manger or Authorized Signature: Exempt Hourly Salary Rate of Pay: $ per Title: Date: Nonexempt Hourly Salary Accurate Time Records Must Be Maintained *Client Company is responsible for completing, verifying, and maintaining I-9 Form for every employee Rate of Pay: $ per Tipped Employees: NO YES Shift Pay: NO YES Rate: $ per Piecework: Commissions: NO YES Rate: $ per NO YES Rate: $ per

4 SECTION 3 EMPLOYEE AGREEMENT I, the undersigned employee, in consideration of my hiring by Advanced PEO Solutions, LLC (APS) as an at-will leased employee of APS, acknowledge and agree to the following: 1. I have been hired as an at-will employee of APS, which is an Employee Leasing Company, and there is no contract of employment which exists between me and the CLIENT COMPANY to which I have been assigned, nor between APS and me. I understand and agree that either APS or I can terminate our employment relationship at any time, as I am an at-will employee. 2. I also agree that while I am a leased employee of APS, if APS does not receive payment from CLIENT COMPANY for services which I perform as a leased employee, APS will still pay me the applicable minimum wage (or the legally required minimum salary or overtime pay) for any such period, and I agree to this method of compensation. I understand that the CLIENT COMPANY to which I am assigned at all times remains obligated to pay me my regular hourly rate of pay if I am a non-exempt employee and to pay me my full salary if I am an exempt employee even if APS is not paid by CLIENT COMPANY to which I am assigned. 3. In recognition of the fact that any work related injuries which might be sustained by me are covered by state workers compensation statutes, and to avoid circumvention of such state statutes which may result from suits against customers or clients of APS or against APS based on the same injury or injuries, and the extent permitted by law, I hereby waive and forever release any rights I may have to make claims or bring suit against CLIENT COMPANY or customer of APS or against APS for damages based upon injuries which are covered under such workers compensation statutes. I also agree to comply with any drug testing policy, which APS may adopt, and I specifically agree to post-accident drug testing in any situation where it is allowed by law. I also agree that if I am injured, unless any other leave program is applicable, I will accept any modified/light duty assignment provided to be within the scope of my physical capabilities as determined by the workers compensation treating physician. 4. I also agree that if at any time during my employment I am subjected to any type of discrimination, including discrimination because of race, sex, age, religion, color, retaliation, veteran status, national origin, handicap, disability or marital status, or if I am subjected to any type of harassment including sexual harassment, I will immediately contact an appropriate person of the CLIENT COMPANY to which I am assigned. In most instances, this appropriate person will be the president of the CLIENT COMPANY. Should I choose not to contact the CLIENT COMPANY for any reason, I may contact APS Human Resource Director at in order to obtain assistance in the resolution of such matters. I understand and agree that APS does not have actual control over my workplace, and as such, is not in a position to end or remediate any discrimination, harassment, or retaliation which may be occurring. The responsibility to end such inappropriate conduct rests solely with the CLIENT COMPANY: however APS will attempt to facilitate a resolution. 5. I understand that I will receive my daily instructions from the co-employer to whom I have been assigned. There will be a 90-day probationary period at which time any party can terminate employment without further obligation. 6. As a drug and alcohol free workplace, APS prohibits, among other things, the unlawful possession, consumption, distribution, or unauthorized use by all employees of alcohol or any illegal drugs or illegally obtained drugs in the workplace or when conducting work. Nor is any employee permitted to work after having ingested illegal or illegally obtained drugs or while impaired or under the influence of alcohol or drugs. Employees can be required to submit to drug and or alcohol testing under certain circumstances in accordance with APS s drug and alcohol free workplace testing program, including post accident and reasonable suspicion testing. Any employee who violates APS s policies may be subject to immediate discharge. Questions concerning APS s drug and alcohol free policies/ testing should be directed to APS Human Resources Director at I further agree that at the end of my assignment with the CLIENT COMPANY, I will report back to APS for possible reassignment to another client. If I fail to report within 48 hours, I may be denied unemployment benefits. By signing below, I acknowledge that I understand all of the items above. I further understand that I am an employee of Advanced PEO Solutions LLC and that Advanced PEO Solutions LLC is my employer of record. Employee Signature Printed Name Date SECTION 4 WORKERS COMPENSATION QUESTIONNAIRE This questionnaire should not be answered unless the applicant has accepted a conditional offer of employment. YES NO 1. Have you ever received treatment for a back, neck or knee condition or head injury? 2. Have you ever had any surgery? 3. Has any injury or illness ever prevented you from gainful employment? 4. Have you ever had an injury on the job? 5. Have you ever received a disability rating for any reason? 6. Have you ever received compensation or medical benefits under workers compensation? 7. Do you have any limitations which may affect your ability to safely or effectively perform the position you are offered? Explain any YES answers: I have been fully advised that if I am injured on the job, regardless of how minor the injury, I am to report that injury immediately to my supervisor. A notice of injury must be submitted by APS to the insurance carrier within 7 days as required by law. I further certify all answers above to be true and correct. I understand any false or misleading answers will be sufficient reason for denial of benefits under the Workers Compensation Act of my state, and will be basis for immediate termination of employment. Employee Signature Witness Date

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